Sunday, December 18, 2011

The Reform Medicare Really Needs

Between now and the elections in November 2012 we're going to hear a lot about Medicare vouchers - or, in the prettied up term, "premium support." We're finally at the point where no responsible politician denies the need to curtail Medicare costs. And, in recent weeks, Democrats as well as Republicans have been floating different forms of voucher proposals for reining in Medicare costs. "Guaranteed Choices to Strengthen Medicare and Health Security for All," the hot-off-the-press proposal from Senator Ron Wyden (D-Oregon) and Representative Paul Ryan (R-Wisconsin) will get the most attention.

The Wyden-Ryan proposal opens with an on-target diagnosis of how virulent Medicare politics has led to the morass we're in:

Few issues draw more heated partisan rhetoric than the future of Medicare. Seniors are a reliable and powerful voting bloc, and both Republicans and Democrats are guilty of exploiting Medicare concerns to frighten and entice voters..In fact, the more the national conversation about the future of Medicare deteriorates into partisan attacks that our opponents will “cut Medicare” versus superficial campaign pledges to “make no changes” to a 45-year-old program, the harder it gets to have a serious debate about the best way to ensure that seniors can rely on a strengthened Medicare program for decades to come.

The debate about Wyden-Ryan and other voucher proposals is predictable. Republicans and a few Blue Dog Democrats (foreign readers - "Blue Dogs" are conservative Democrats) will fight for vouchers on the basis of free market theology of choice and competition. Yellow Dog Democrats (foreign readers - "Yellow Dogs" are so loyal they would vote for a yellow dog if it was called a Democrat) will fight to keep fee-for-service Medicare as it is, with tweaks to reduce costs.

Both positions are wrong. They ignore the two most important constituents - Medicare beneficiaries themselves and the improvement-minded clinicians who care for them.

We Medicare beneficiaries (I say "we" even though I'm only a Medicare "eligible," since I still have employer insurance) don't want to mortgage opportunity for future generations to pay for the bloated system we have now. The 77% of us with traditional Medicare like the government-run insurance program. The 23% of us with Medicare Advantage plans are happy with private insurance. But we're not happy with the discoordinated care system in which tests are repeated unnecessarily, doctors don't communicate with each other, we get readmitted to the hospital too quickly, and, at the end of life, too often die surrounded by monitors and tubes in the ICU rather than by our loved ones at home. And our physicians and nurses are frustrated by many of the same things.

To get real Medicare reform three things must happen:

Medicare beneficiaries must speak out about improving care and protecting future generations by reducing costs. Politicians imagine that we're all "greedy geezers" like the folks who threaten them in the recent AARP advertisement. Some of us are, but it's a minority. Our political leaders won't get serious until they hear from us - their constituents - about what most of us believe and want.

Improvement-minded physicians, nurses, other health professionals, and administrators are the ones who know how to wring the waste, estimated to be as high as 30%, out of the care system. Competition won't do it. Vouchers won't do it. Only motivated health professionals can. If you want to understand why this is so, read Don Berwick's recent address to the Institute of Health Improvement.

Medicare needs a budget. Creating a budget by adding up the bills for our care won't do the job. If there's a true budget we can work with out caretakers to do what's needed within fair limits. Most of us are on fixed incomes. We know there's no pie in the sky!

For 35 years I practiced and got my own care at a not for profit HMO where clinicians and patients lived within a budget and made the system work. I'd rather see us use patient-physician collaboration as the basis for Medicare reform rather than hope that financial pressure will turn Medicare beneficiaries into health care shoppers who drive costs down. But quite apart from the prevailing conservative faith-based belief that "skin in the game" will inevitably fuel the needed reforms, it's not irrational to fear that politicians won't have the gumption to create and stick to a true budget for Medicare, or to allow CMS to apply sensible management strategies like centers of excellence instead of unbridled fee-for-service. It's that perspective that leads Democrats like Senator Wyden to take up the voucher concept.

But with or without vouchers, with or without either single payer Medicare or multiple competing insurers, the key ingredients of Medicare reform are (1) strong beneficiary demand for positive change, (2) leadership from improvement-minded clinical leaders, and (3) an overall budget for the program. Without this triad we're just whistling into the wind.